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Abstract

Background: Deficiency of iodine causes goiter which is a visible sequelae. One of the major impacts of iodine deficiency is that it can lead to impaired neurodevelopment particularly in early life. Goiter surveys are conducted to identify areas of IDD and can be used as a baseline assessment of a region’s iodine status and as a sensitive long-term indicator for the success of an iodine programme. Methodology: This cross-sectional study was conducted among 6-12 years children by the Department of Community Medicine, Government Medical College, Srinagar, in collaboration with Department of Drug and Food Control Organization under NIDDCP, in district Anantnag, Kashmir division (J&K) during the month of March and April, 2017. The sample size of 2700 was calculated using the method of Population Proportionate to Size (PPS) sampling in the age group of 6-12 years children. Demographic variables and goiter grade was recorded by trained health professionals, assessment of goiter was done clinically by inspection and palpation of the thyroid gland. Results: In this study, we studied a total of 2700 school children in the age group of 6-12 years from district Anantnag with mean age of 9.69 ± 2.02 years. 50.7% were boys. The age distribution prevalence of goiter was observed to be 13.8% with highest prevalence seen among schools children of age 8-10 years (45.8%). The prevalence of grade 1 goiter was more than ten folds higher than grade 2 goiter. It has been observed that Achabal and Mattan zone have higher prevalence of grade 1 & grade 2 Goiter 22.40% and 22.22% respectively. Achabal and Mattan zone have goiter prevalence of moderate severity and outnumber other zones. Conclusion: The present study shows that Kashmir division is still an endemic area, where goiter remains a significant public health problem. Effect of geographical locations, dietary factors, storing salt techniques, cooking techniques and interaction of iodine with other nutrients are some areas where further research can be done in future.

Keywords

Goiter survey; Northern India; School children; Goiter in Children; IDD in children

Introduction

The hormones produced by the thyroid gland require iodine as
an essential component and these hormones are essential for
sustaining human life, therefore iodine is crucial for human
development and survival. Deficiency of iodine causes goiter
which is a visible sequelae, clinically detected by physical
inspection and palpation of the thyroid gland. One of the major
impacts of iodine deficiency is that it can lead to impaired
neurodevelopment particularly in early life. [1] Persistent iodine
deficiency can eventually affect growth and mental development
in all age groups in the same geographic areas irrespective
of their socio-economical status. [2] The prevalence of goitre
increases with the severity of iodine deficiency and becomes
endemic in populations where the intake of iodine is less than
10 μg per day. [3]

World over, around 740 million people are affected by goiter
and 2.2 billion people (over 38% of the global population in
130 countries) live in iodine deficient regions, thus under risk
of Iodine deficiency disorder [IDD] According to the World
Health Organisation (WHO), Iodine deficiency is the single
most common cause of preventable mental handicap worldwide.
[4] Many countries including India, Pakistan and China have
recognised their entire population at risk of IDD. [5] In India,
more than 200 million people reside in geographically goiter endemic areas and 71 million suffer from iodine deficiency
disorders. [6]

The surveys conducted by Central and State health Directors,
ICMR, and Medical institutes have clearly demonstrated that
not even a single state or union territory in the India is free
from spectrum of IDDs. Out of 390 districts surveyed in all
the 29 States and 7 UTs, 333 has been found endemic i.e.,
where the prevalence of Iodine Deficiency Disorders (IDDs) is
more than 5%. [7] Fortification of salt with iodine is the widely
accepted preventive strategy to fight against IDD. Several
studies carried out in India have shown a high percentage of
goiter incidences. [8,9] It has been made mandatory to iodinize all
table salts in India to eliminate iodine deficiency. Government
of India has relaunched National Iodine Deficiency Disorders
Control Programme (NIDDCP) in the year 1992 with a goal to
reduce the prevalence of IDD to non-endemic level. It has been
noticed that after implementation of NIDDCP, India has made considerable progress toward IDD elimination. [10] In this regard
in 2005, central government has issued notification banning
the sale of noniodized salt for direct human consumption in the
entire country, which was effective from May, 2006 under the
Food Adulteration Act. [10]

The common manifestation of IDD is the enlargement of the
thyroid gland and survey method is used as a diagnostic tool to
detect IDD in the community. Goiter surveys are conducted to
identify areas of IDD and can be used as a baseline assessment
of a region’s iodine status and as a sensitive long-term indicator
for the success of an iodine programme. [4] The school age
children are usually taken into account as the Iodine deficiency
causes an immediate effect on the child’s school performance
[2,3] and they represent a useful population for the assessment
of IDD, both because of their accessibility through schools and
physiological vulnerability. [11] Literature search reveals that
many studies have been conducted in different parts of India and
Kashmir division to estimate the burden of IDD, no such study
has been conducted in district anantnag of Kashmir division
which lies in the southern sector of Jhelum Valley about 60
kms from the summer capital of Jammu & Kashmir. Owing to
proximity of Peer Panchal Range, this stretches in its south and
south-east regions. A well-known fact about goiter is its high
prevalence in hilly regions possibly owing to the soil and water
deficient in iodine compared to low lying areas. In view of this,
we conducted this goiter survey among school going children of
district anantnag, Kashmir division to see prevalence of IDD.

Methods

This cross-sectional study was conducted among 6-12 years
children, in district Anantnag, Kashmir division (J&K) during
the month of March and April, 2017. The sample size of 2700
was calculated using the method of Population Proportionate to
Size (PPS) sampling in the age group of 6-12 years children as
per recommended guidelines of WHO/UNICEF/ICCIDD. [10-12]
Anantnag district was divided into five educational zones and
the list of all the schools were collected from official website
of the district. [13] Prior permission to conduct the survey was
obtained from the Director of education department and
informed consent from zonal education officer and school heads
before the start of the study. A total of 30 schools were selected
from the whole district, six from each zone. A sample of 90
school children (45 boys and 45 Girls) in the age group 6 -12
years were randomly selected from each school. Thus, a total
of 2700 students were examined to achieve the required sample
size. Demographic variables and goiter grade was recorded by
trained health professionals from the department of Community
Medicine who had obtained prior training for case identification
and goiter grading.

Assessment of goiter was done clinically by inspection and
palpation of the thyroid gland and graded as per World Health
Organization (WHO) grading system and revised guidelines
under National Iodine Deficiency Disorders Control Programme
(NIDDCP). [14]

Grade 0, No Goiter (No palpable or visible goiter)

Grade 1 (Goiter palpable but not visible) and

Grade 2 (Goiter visible and palpable in normal position of neck)

Data was entered in Microsoft excel spreadsheet 2007 and
analyzed in SPSS v 20.0. The outcomes variables are expressed
in percentages based on age, sex and goiter grade.

Results

In this study, we studied a total of 2700 school children in the age
group of 6-12 years from district Anantnag with mean age of 9 ±
1.86 years. 50.7% were boys. The age distribution prevalence of
goiter among school children (6-12 years) in district Anantnag
is shown in Table 1, which was observed to be 13.8% [95%
CI=13.14-14.46] with highest prevalence seen among schools
children of age 8-10 years (45.8%). The prevalence of grade 1
goiter was more than ten folds higher than grade 2 goiter. Table 2 shows sex distribution of Grade 1 and grade 2 goiter cases
in district Anantnag with slightly higher prevalence of grade 1
goiter in girls and grade 2 goiters in boys. The distribution of
goiter prevalence among boys and girls in different educational
zones of district Anantnag is shown in Table 3. It has been
observed that Achabal and Mattan zone have higher prevalence
of grade 1 & grade 2 Goiter 22.40% and 22.22% respectively.
The severity score of Goiter as a major public health problem
is shown in Table 4. [15] Achabal and Mattan zone have goiter
prevalence of moderate severity and outnumber other zones.

Age in years

Total no. of children examined

Goiter Prevalence

Grade 1

Grade 2

Total Goitre (%)

N (%)

N (%)

6

230

33 (14.3)

3(1.3)

15.6

7

292

35(12.0)

4(1.4)

13.3

8

314

50(15.9)

1(0.3)

16.2

9

339

48(14.2)

4(1.2)

15.3

10

348

47(13.5)

3(0.9)

14.3

11

421

52(12.4)

5(1.2)

13.5

12

756

81(10.7)

7(0.9)

11.6

Total

2700

346(12.8)

27(1.0)

13.8

Table 1: Age distribution of children with goiter in Anantnag District.

Table 3 : Distribution of goiter grade in educational zones of district Anantnag.

Study Zone

Total no. of children examined

No.(%) of children with Goiter

*Severity

Grade 1 (%)

Grade 2 (%)

Total (1+2)

District Headquarter

540

9.8

0.5

10.3

Mild

Bijbehara

540

9.2

0.1

9.4

Mild

Qazigund

540

4.6

0

4.6

No

Achabal

540

19.2

3.1

22.4

Moderate

Mattan

540

21.1

1.1

22.2

Moderate

Total

2700

12.8

1

13.8

Mild

*<5% No; 5-19.9% Mild; 20-29% Moderate; >30% Severe

Table 4: Distribution of severity of Goitre as a public health Problem in educational zones of district Anantnag.[15]

Discussion

In India, previous studies had shown that no states or union
territories were free from IDD Iodine deficiency disorders (IDD)
although being preventable disorders. [16,17] For assessment of
the severity of the iodine deficiency of any geographical area,
WHO/UNICEF/ICCIDD had established the criteria on the basis
of total goiter prevalence (palpable and visible goiter). [14] Any
geographical area is classified as endemic for iodine deficiency
when a total goiter prevalence rate in that area is more than 5%
among school children aged 6-12 years. [7,15] With an objective to
find the prevalence of IDD in district Anantnag, we conducted
goiter survey in 2700 school children aged 6-12 years and found
that the total goiter prevalence was 13.8% [95% CI=13.14-
14.46] The presence of goiter among boys and girls were almost
equal with fewer gender differences. This finding proved that
individual sex has no role in IDD and it’s the consumption of
iodine as salt with foods that make the difference. [18] In our
study, the prevalence rates of grade 1 goiter and grade 2 goiter
were found to be 12.8% and 1.0% respectively. An earlier
study by Khan SMS et al. in 2014 reported 18.9% prevalence
of goiter in children aged 6-12 years in Kashmir division where
18.5% of children had grade 1 goiter and 0.4% had grade 2nd
goiter. [19] This finding shows that over a period of time, the
overall prevalence of total goiter and grade 1 goiter has fallen
considerably which may be attributed to consumption of iodized
salt while the prevalence of grade 2 goiters has slightly increased.
This may be due to the endemic nature of the disease itself and
asymptomatic cases which often get unnoticed. Another study
from Kashmir by Rafiq et al. found the total Goiter Rate (TGR)
as 15.27%; 16.35% among girls and 13.38% among boys.
[20] Zargar AH et al. in 1997 conducted a study among school
children aged 5-15 years in Kashmir valley and found a TGR
of 45.2%; 43.9% among boys & 46.23 among girls. 37.74% of
children had grade 1 goiter and 7.44% had grade 2nd goiter. [21]
Many studies including ours show that the prevalence of goiter
has declined in the valley over time but still it is a major public health problem. The decrease in the prevalence of goiter can
be attributed to continuous efforts of the government and nongovernment
organizations by banning the sale of non-iodized
salt, increase in the literacy rate in the population, awareness
among people through electronic and print media and the role
of medical professionals at an individual level.

Moreover, we found a unique pattern in the prevalence of goiter
with age. The prevalence of goiter was found to be rising from
6 years, maximum among 8-10 years and then declining till age
12 years. A maximum number of cases were seen in the age
group of 8 years (16.2%). Similar findings were reported by a
study conducted in Gujarat by Chandwani HR et al. in 2012 and
Wolka E in the year 2014 [22] who found that with advancing
age, the prevalence of goiter decrease with a maximum number
of cases in the median age group. [23] The increased demand of
thyroid hormone with advancing age may be attributed to this
relation of age and prevalence. Another finding of our study reports the inter zonal goiter prevalence with Achabal and
Mattan zones having moderate severity goiter prevalence. It has
been overwhelming that we didn’t found any zone with high
severity goiter prevalence.

World health organization urged to implement Universal salt
iodization (USI) and iodine supplementation strategies for
preventing and controlling iodine deficiency disorders. National
goiter control program was launched in 1962 by Government of
India and renamed National iodine deficiency disorder control
programme [NIDDCP] in 1992 with the aim to reduce the
prevalence of IDD to below 10% by 2010. [24] After 25 years of
implementation of NIDDCP, the present study shows that the
national programme has had much impact in lowering down the
prevalence of goiter in district Anantnag, Kashmir division.

Recommendations

Interventions should be designed with an aim at increasing the awareness of the health benefits of iodine in the diet, and
the increasing use of iodized salt at the domestic level. The
interventions should be sensitive enough to the local culture and
should consequently enhance the intervention process. Health
education regarding the use of iodized salt to different cadres
of the community members at the house hold level, visits to the
schools, visit to the health centers should be done on regular
basis. Education sessions should be given at the village health
centers, religious gatherings, during immunization sessions and
by motivating the people with the help of ASHA. Though the
study was well organised with adequate sample size, it had some
limitations. The casual factors responsible for IDD in children
were not studied in detail due to time constrains and poor
knowledge of students about IDD which could have introduced
bias in the study.

Conclusion

The present study shows total goiter prevalence of 13.8% in
district Anantnag, Kashmir division indicating that it is still an
endemic area, where goiter remains a significant public health
problem. Though the prevalence of goiter has been reduced
over years, it is still endemic. Effect of geographical locations,
dietary factors, storing salt techniques, cooking techniques and
interaction of iodine with other nutrients are some areas where
further research can be done in future.

Acknowledgements

The authors would like to acknowledge the services and
assistance of the Directorate of Education, Chief education
officers, Principals/Head of Institutions, Teachers and students
who took part in the survey.

Conflict of Interest

All authors disclose that there was no conflict of interest.

References

Zimmermann MB. The role of iodine in human growth and development. Endocr Pract. 2013; 19: 839-846.